Coming at you with another outstanding Clinical Problems in Consultation Psychiatry (CPCP). This one compares two eating disorders and their treatment outcomes: Avoidant Restrictive Food Intake Disorder (ARFID) and Anorexia Nervosa.
A hard-working medical student put this together, Allison Kim. She’s a senior who’ll be going into Emergency Medicine. She’s a great learner and a great teacher.
“When you learn, teach, when you get, give.”–Maya Angelou.
We had a pretty good size group of learners for this CPCP. One of them is a second year medical student (Mohamed Salih, on the far left in the picture below) who is showing a strong interest in psychiatry. Some of my readers may recall Dr. Emily Morse from previous CPCPs. Dr. Qiang Zhang (far right) is an excellent senior Neurology resident. Ally is next to him. The guy in the middle is some geezer.
It turns out that patients with both disorders do fairly well with psychiatric treatment, either on inpatient units or in partial hospital programs.
I may as well confess I’m not so sure about the last diagnostic criterion for ARFID: “The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.”
Many gastrointestinal medicine specialists call me about their patients who apparently fit every criterion for ARFID except for that one. In fact the concurrent medical condition can be critically important in the development of disordered eating–which may not be that different from formal eating disorders in terms of consequences. They’re pretty convinced that psychiatrists need to be more involved in collaborating with them about managing persons with ARFID.
Disordered eating can be triggered by gastrointestinal disease and it includes food restriction, skipping meals, and over-eating. It can lead to the development of an eating disorder and that can sometimes challenge the paradigm of psychiatric treaters.
The prevalence of disordered eating among those with gastrointestinal diseases exceeds the rates found in the general disorder, maybe by as much as 40%. They can develop food aversions as a result of distressing gastrointestinal symptoms and that can lead to dietary restrictions. Conceivably this can progress to harmful thoughts and attitudes towards food and body weight.
In the opposite direction, patients with eating disorders such as anorexia nervosa can develop functional gastrointestinal disorders. And organic gastrointestinal disease and eating disorders can coexist. When both are present, they can perpetuate each other.
While it’s important to keep a both/and perspective in mind, there are a few key questions to ask to help identify eating disorder vs disordered eating:
- Is the driving force behind the weight loss or poor weight gain due to a distortion in body image and desire for thinness?
- Do you suspect psychiatric complexity beyond expected demoralization about their illness?
- Is the patient reluctant to work with you on improving weight because of a fear of gaining weight?
- Is the anxiety about eating out of proportion to their limitations due to medical illness?
By the way, there is a very interesting perspective on eating disorders and how the starved brain can make those with disordered eating and eating disorders look very similar. You can find it at the National Neuroscience Curriculum Initiative (NNCI) website. Registration is free.
And you can learn more about CPCP here.
It’s one way to meet the core competency of Practice-based Learning and Improvement. My former teacher, Dr. William R. Yates, MD, and a former Chief Resident, Dr. Terri Gerdes, wrote a paper about it, when it was called problem-based learning:
“Yates, W. R. and T. T. Gerdes (1996). “Problem-based learning in consultation psychiatry.” Gen Hosp Psychiatry 18(3): 139-144.Yates, W. R. and T. T. Gerdes (1996). “Problem-based learning in consultation psychiatry.” Gen Hosp Psychiatry 18(3): 139-144. Problem-based learning (PBL) is a method of instruction gaining increased attention and implementation in medical education. In PBL there is increased emphasis on the development of problem-solving skills, small group dynamics, and self-directed methods of education. A weekly PBL conference was started by a university consultation psychiatry team. One active consultation service problem was identified each week for study. Multiple computerized and library resources provided access to additional information for problem solving. After 1 year of the PBL conference, an evaluation was performed to determine the effectiveness of this approach. We reviewed the content of problems identified, and conducted a survey of conference participants. The most common types of problem categories identified for the conference were pharmacology of psychiatric and medical drugs (28%), mental status effects of medical illnesses (28%), consultation psychiatry process issues (20%), and diagnostic issues (13%). Computerized literature searches provided significant assistance for some problems and less for other problems. The PBL conference was ranked the highest of all the psychiatry resident educational formats. PBL appears to be a successful method for assisting in patient management and in resident and medical student psychiatry education.”
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